1. Institutions and Culture Health Policy and Public Opinion in the U.S. and Britain By Lawrence Jacobs (1992)

2. Introduction Compares the formulation of the British NHS act of 1945 and the Am. Medicare act of 1965 Objective: to explore the role of public preferences in the policymaking processes leading to the NHS and Medicare acts →NHS: free medical service to all; Medicare: medical service limited to the aged and the poor Jacobs: ► traditional institutional analysis: public preferences often seen as relevant only for selecting political leaders, not for institutional change (= new administrative arrangements) ► main argument: public preferences have played a major role in influencing policy in both countries ► strong public sentiment → weak IG (and elite) influence → increased state autonomy Next: Method; Concepts; Two Theoretical approaches; Empirical evidence

3. Method Study design: most similar cases (UK and US) –same language –sceptical to broad state intervention –support to individual freedom Main dependent variable: NHI policy reform (new institutional arrangements) Main independent variables: public preferences (public opinion) vs state capacity and state autonomy

4. Concepts Two theoretical approaches reviewed: institution-based and culture-based analysis ’Institutions’: viewed in terms of state capacity and state autonomy, usually referring to administrative arrangements (better than state ’strength’ & ’weakness’) →Jacobs refers to contemporary Weberian-based analysis, but here I term this institution-based analysis (state-centred) ’Culture’ is treated in two different ways in culturalist analysis (Jacobs applies both) (1) The political culture tradition: using polls to find public opinion; equating culture with the preferences of individuals (temporary) (2) Meaning-centred approaches; using social historical research to find the enduring public understandings (national culture seen as organised social interaction)

5. Theory 1: Institution-based approaches to institutional change State capacity –the ’objective’ administrative capacity of the state (specialisation and hierarchy). Also perceived as political effectiveness or performance –the state’s existing administrative capacity important for future institutional changes (determinism) –both UK and US: weak state capacity (dispersal of authority) State autonomy –a function of state capacity –the degree of independence from IG pressure –assumed that policymakers respond to IGs, but the state can act independently when needed Jacobs’ main critique: the preferences and understandings of the public are ignored

6. Theory 2: Culture-based approaches to institutional change Culture in society impacts on everyone; even elites share some common societal values No such thing as an ’objective’ administrative capacity of the state; institutions and culture are closely linked: ”..institutions embody the organized existence of culture” Environment (e.g. adm capacity) ↓ Culture ↓ Behaviour → culture helps members in society to understand and respond to the environment

7. Theory 2: Culture-based approaches to institutional change (cont.) Jacobs’ assumption: general aspects of culture underlie the public’s specific preferences Example from social historical research: –UK and US: poor laws originally conceived of in negative terms, but gradual change in the UK since the initial law of 1601→ the public gradually got used to state involvement in health care (US: public focus on political rights only) – thus: the British public is still today more accustomed to state involvement in health care than the American public Jacobs’ main critique: approach fails to explain how culture influences changes in state capacity; causal significance of culture often exaggerated; state actors do make strategic policy calculations and policy networks do exist

8. Health policy in the US and the UK: the formulation of Medicare and the NHS acts 1)State autonomy: How independent were state actors from medical IGs in the two countries? → Institutionalists expect: state autonomy a function of adm capacity (Weak Am state: minimal independence) → Culturalists expect: state autonomy depends on the policymakers’ perceptions of public preferences and understanding -Findings US: 1) Decision to use the Social Securtiy System to finance health care for the elderly; in accordance with P.O.→weak IG influence. 2) However, limited NHI to basic hospital coverage (Am Med Ass: ’socialised medicine’)→ strong IG influence -Findings UK: 1) Decided that health services should be available to all; in acc with P.O. →weak IG influence. 2) However, doctors allowed private practice in the gov-financed health service→ strong IG influence.

9. State autonomy (cont.) Jacobs: -The fact that IGs exerted both weak and strong influence simultaneously within one policy area challenges the institutional (state-centred) view of state autonomy; even though state capacity was relatively weak in both countries, state autonomy was high on specific issues -Also, these examples show that the degree of state autonomy is not a function of administrative capacity. Instead, public preferences were balanced with IG claims

10. 2) State capacity: predicting how administrative arrangements would be designed for the NHS and Medicare → Institutionalists expect: the technical adm aspects of the state important (Weak adm resources in health policy in the US→ weak hierarchical control, low specialisation) → Culturalists expect: public preferences and understanding important -Findings UK: Central state control of all hospitals; in line with P.O.→ weak IG influence (wanting to retain independence for some hospitals). →Jacobs: This is partly consistent with the institutionalist concept of state capacity, but still, state-centred theory disregards the role of public preferences in this decision (in favour) -Findings US: Decentralised reimbursement arrangements gave the state a weak adm arrangement without hierarchical control. This balanced the public preference of some state financing of hospitals, while keeping down the impression of state interference. →Jacobs: This is partly consistent with institutionalist expectations of weak state capacity in the US based on the weak Am state, but still compatible with the ’cultural’ explanation (P.O. in favour of some state financing)

11. Conclusion Strong P.O.→ Weak IG influence Weak P.O. → Strong IG influence -Thus: despite relatively weak adm capacity in the US, the state remained independent from IGs on specific policy issues. Public sentiment played a critical role in shaping specific administrative arrangements -Article mirrors state-society theory; culture has an impact on state capacity and autonomy; Jacobs recommends to pay more attention to public opinion in studying policy change; he promotes democratic theory which calls for greater citizen influence over policymaking. Critique: -No discussion of time frame; social context very different in 1945 and 1965 -Mixing of ’culture’ and ’P.O.’

12. Comparing the articles’ use of theories Jacobs - Dep.Var.: New Institutional Arrangements (NHI reform) US & UK - Indep.Var.: ►public pref & cultural understanding ►state autonomy ►state capacity Maioni - Dep.Var.: NHI systems Canada & US - Indep.Var.: ► federalism ► party discipline ► pro-WS-political parties Social context theories –Structural –Cultural –Convergence Actor-centred theories –IGs –Political parties –State-centred –State-society (civil soc) Institutionalist theories